| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
308 |
308 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
386 |
386 |
$23K |
| D0210 |
Intraoral - complete series of radiographic images |
233 |
232 |
$11K |
| D1120 |
Prophylaxis - child |
212 |
212 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
147 |
147 |
$9K |
| D1206 |
Topical application of fluoride varnish |
508 |
508 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,133 |
401 |
$5K |
| D4910 |
|
46 |
46 |
$3K |
| D0350 |
|
234 |
111 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
18 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
186 |
$2K |
| D0274 |
Bitewings - four radiographic images |
124 |
124 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$1K |
| D9430 |
|
12 |
12 |
$384.00 |